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Crash of an Airbus A320-231 in Phoenix

Date & Time: Aug 28, 2002 at 1843 LT
Type of aircraft:
Operator:
Registration:
N635AW
Survivors:
Yes
Schedule:
Houston - Phoenix
MSN:
092
YOM:
1990
Flight number:
AWE794
Crew on board:
5
Crew fatalities:
Pax on board:
154
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19500
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
11000
Copilot / Total hours on type:
800
Aircraft flight hours:
40084
Aircraft flight cycles:
18530
Circumstances:
After an asymmetrical deployment of the thrust reversers during landing rollout deceleration, the captain failed to maintain directional control of the airplane and it veered off the runway, collapsing the nose gear and damaging the forward fuselage. Several days before the flight the #1 thrust reverser had been rendered inoperative and mechanically locked in the stowed position by maintenance personnel. In accordance with approved minimum equipment list (MEL) procedures, the airplane was allowed to continue in service with a conspicuous placard noting the inoperative status of the #1 reverser placed next to the engine's thrust lever. When this crew picked up the airplane at the departure airport, the inbound crew briefed the captain on the status of the #1 thrust reverser. The captain was the flying pilot for this leg of the flight and the airplane touched down on the centerline of the runway about 1,200 feet beyond its threshold. The captain moved both thrust levers into the reverse position and the airplane began yawing right. In an effort at maintaining directional control, the captain then moved the #1 thrust lever out of reverse and inadvertently moved it to the Take-Off/Go-Around (TOGA) position, while leaving the #2 thrust lever in the full reverse position. The thrust asymmetry created by the left engine at TOGA power with the right engine in full reverse greatly increased the right yaw forces, and they were not adequately compensated for by the crew's application of rudder and brake inputs. Upon veering off the side of the runway onto the dirt infield, the nose gear strut collapsed. The airplane slid to a stop in a nose down pitch attitude, about 7,650 feet from the threshold. There was no fire. Company procedures required the flying pilot (the captain) to give an approach and landing briefing to the non flying pilot (first officer). The captain did not brief the first officer regarding the thrust reverser's MEL'd status, nor was he specifically required to do so by the company operations manual. Also, the first officer did not remind the captain of its status, nor was there a specific requirement to do so. The operations manual did state that the approach briefing should include, among other things, "the landing flap setting...target airspeed...autobrake level (if desired) consistent with runway length, desired stopping distance, and any special problems." The airline's crew resource management procedures tasked the non flying pilot to be supportive of the flying pilot and backup his performance if pertinent items were omitted from the approach briefing. The maintenance, repair history, and functionality of various components associated with the airplane's directional control systems were evaluated, including the brake system, the nose landing gear strut and wheels, the brakes, the antiskid system, the thrust levers and reversers, and the throttle control unit. No discrepancies were found regarding these components.
Probable cause:
The captain's failure to maintain directional control and his inadvertent application of asymmetrical engine thrust while attempting to move the #1 thrust lever out of reverse. A factor in the accident was the crew's inadequate coordination and crew resource management.
Final Report:

Crash of a Beechcraft E90 King Air in Flagstaff: 3 killed

Date & Time: Jan 31, 1996 at 1305 LT
Type of aircraft:
Operator:
Registration:
N300SP
Flight Type:
Survivors:
No
Site:
Schedule:
Flagstaff - Phoenix
MSN:
LW-166
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10700
Captain / Total hours on type:
613.00
Aircraft flight hours:
5952
Circumstances:
The pilot and 2 nurses departed IFR to transport a patient from another location. During the initial climb, the pilot observed a gear unsafe light. He requested clearance to an area of VFR conditions to address the gear problem. Subsequently, the gear was manually extended with safe gear indications. The flight department requested that the pilot return to base. The pilot obtained an IFR clearance to return for an ILS approach. After handoff to the tower, he was requested to report the FAF inbound after an eastbound procedure turn. That was the last communication from the pilot. Subsequently, the aircraft crashed on the southeast side of Humphreys Peak at an elevation of about 10,500 feet and about 10 miles west of the final approach course. Wreckage was scattered along a heading of 230 degrees. There was evidence that the airplane was in a steep descent when it crashed. Radar data revealed an outbound track west of the published course and no procedure turn. The weather was IMC with light snow and rain. Moderate to severe turbulence was forecast and confirmed by other pilots. The winds at 10,000 feet were forecast to be 50 knots out of the southwest. Moderate turbulence and light rime ice had been reported along the ILS approach course before to the accident time.
Probable cause:
Failure of the pilot to follow prescribed IFR procedures and his failure to maintain control of the aircraft. Factors relating to the accident were: the adverse weather conditions with icing and turbulence.
Final Report:

Crash of a Convair CV-440F Metropolitan in Spokane

Date & Time: Jan 4, 1996 at 1853 LT
Operator:
Registration:
N358SA
Flight Type:
Survivors:
Yes
Schedule:
Phoenix - Spokane
MSN:
153
YOM:
1954
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5194
Captain / Total hours on type:
817.00
Aircraft flight hours:
8642
Circumstances:
Before the ferry flight, the pilot (PIC) & inexperienced copilot noted the left & right, float-type, underwing, fuel gauges indicated about 3,900 & 4,050 lbs of fuel, respectively. After takeoff, they noted that the cockpit gauges showed an opposite fuel imbalance of 4,100 & 3,600 lbs in the left & right tanks. Due to this indication, the PIC crossfed fuel from the left tank to both engines for about 30 min to rectify the perceived fuel imbalance. Later as they approached the destination, the left tank was exhausted of fuel, & the left engine lost power, although the left gauge indicated about 500 lbs of fuel remaining in that tank. The PIC then crossfed fuel from the right tank to both engines, & left engine power was restored. ATC vectored the flight for an emergency ILS runway 3 approach. The PIC was distracted during the approach & maneuvered the airplane to re-intercept the localizer. About 500' agl in IMC, both engines lost power. During a forced landing at night, the airplane struck a raised berm & was damaged. No evidence of fuel was found in the left tank; 125 gal of fuel was found in the right tank. Unusable fuel was published as 3 gal. During an exam of the engines & fuel system components, no preimpact failure was found. Historical data from the manufacturer indicated that when the airplane had a low fuel state, unporting of fuel tank outlets could occur during certain maneuvers. This information was not in the Convair 340 flight manual, although unporting of the outlets on this flight was not verified.
Probable cause:
The pilot's improper management of the fuel/system, which resulted in loss of power in both engines, due to fuel starvation. Factors relating to the accident were: false indications of the cockpit fuel gauges, darkness, and the presence of a berm in the emergency landing area.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Flagstaff: 1 killed

Date & Time: Jan 11, 1995 at 1805 LT
Type of aircraft:
Operator:
Registration:
N746FE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Flagstaff - Phoenix
MSN:
208-0236
YOM:
1990
Flight number:
FDX7551
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Captain / Total hours on type:
2000.00
Aircraft flight hours:
2439
Circumstances:
A witness located near the departure end of the runway saw the airplane initially climb in a normal manner, then stay below the clouds and make a shallow bank 180-degree left turn and descend below a tree line. Tower tapes revealed that the pilot twice transmitted that he was "coming back" to the airport during which the background sound of the "fuel selector off" warning horn was heard. The pilot then informed the controller "I've got to get back", and no warning horn was heard. The airplane collided with trees and came to rest about 6,500 feet sse of the runway's end. Prior to departure, the airplane was refueled with 40 gals of jet a (20 gals per tank), which increased the total fuel load to 148 gals. The flight manual required that the fuel balance between the left and right tanks be kept within 200 pounds, and suggested turning off one fuel selector to correct unbalance situations. The condition of one fuel selector turned off will cause the "fuel selector off" warning horn to sound. Exam of the aircraft revealed no evidence of preimpact failures. Prop blade butt signatures indicated it was operating in the governing range, and engine power was being produced at impact.
Probable cause:
The pilot's failure to properly configure the aircraft fuel system prior to takeoff, and his failure maintain an adequate terrain clearance altitude while maneuvering to return to the airport. Factors in the accident were the dark night lighting conditions, low ceilings, restricted visibility conditions, and the pilot's diverted attention which resulted from activation of the airplane's fuel selector warning horn system.
Final Report:

Crash of a Rockwell Sabreliner 60 in Phoenix

Date & Time: Nov 7, 1992 at 2226 LT
Type of aircraft:
Registration:
N169RF
Flight Type:
Survivors:
Yes
Schedule:
Salina - Phoenix
MSN:
306-45
YOM:
1969
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8456
Captain / Total hours on type:
961.00
Aircraft flight hours:
9366
Circumstances:
Upon landing at the completion of a cross country flight, the captain of the turbojet aircraft employed aerodynamic braking and thrust reverse to slow the airplane to about 60 knots. The captain was allowing the airplane to roll toward the end of the runway where the owner/copilot's hanger was located. With about 4,000 feet of runway remaining, the captain applied the brakes. No braking action was noted. The airplane continued off the end of the runway, through a fence and block wall into a parking lot where the left wing of the airplane was severed. A post crash fire consumed about half of the airplane. Emergency braking procedures were not employed. The crew reported that the were unable to shut down the engines. The copilot lacked experience in the aircraft and crew coordination during the approach, landing, and emergency was ineffective. The airplane traveled about 11,000 feet from point of touchdown to point of rest. Examination of the braking and hydraulic systems failed to pinpoint a malfunction.
Probable cause:
The delay of the pic to apply normal braking and his failure to execute the appropriate emergency procedures. Contributing to this accident was an undetermined antiskid malfunction; the copilot's inexperience in the aircraft; and inadequate crew coordination.
Final Report:

Crash of a Rockwell Grand Commander 690 in Wichita: 2 killed

Date & Time: Nov 2, 1991 at 1206 LT
Registration:
N799V
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wichita - Phoenix
MSN:
690-11407
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4900
Captain / Total hours on type:
1078.00
Aircraft flight hours:
3480
Circumstances:
The pilot and his wife departed Wichita, Kansas with a destination of Phoenix, Arizona. Eight minutes after takeoff, while in a climb to 15,000 feet, the passenger contacted departure control and communicated that she thought that her husband might be dead. While departure control was getting a pilot to assist in the situation, the passenger, who was not a pilot attempted to fly the aircraft. A witness reported a rapid series of climbs and descents just before both horizontal stabilizers and the rudder separated from the aircraft. The aircraft then entered a spin terminating with ground impact. The aircraft was consumed by a post-crash fire. Both occupants were killed.
Probable cause:
Incapacitation of the pilot in command, followed by the loss of control and an inflight breakup with a unqualified person on the controls.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Flagstaff: 1 killed

Date & Time: Sep 21, 1990 at 0545 LT
Operator:
Registration:
N3558
Flight Type:
Survivors:
No
Schedule:
Phoenix - Flagstaff
MSN:
31-8052072
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5000
Captain / Total hours on type:
2500.00
Aircraft flight hours:
5293
Circumstances:
The aircraft was on a night flight from Phoenix to Flagstaff, AZ, to deliver cargo in accordance with an air taxi delivery schedule. Before reaching Flagstaff, the pilot canceled his IFR clearance and proceeded VFR. He encountered lowering cigs and rw. During the approach, he extended the landing gear and partially extended the wing flaps. Subsequently, the aircraft hit trees and crashed in an unpopulated area about 2.5 miles south-southeast of the airport at an elevation of about 6,800 feet; airport elevation was 7,011 feet. Initial impact occurred while the aircraft was in a right 20° bank (toward runway 03). Weather data at the company dispatch was not current and did not depict the adverse local conditions near the destination airport. The pilot, sole on board, was killed.
Probable cause:
VFR flight by the pilot into instrument meteorological conditions (IMC), and his failure to maintain proper altitude during the approach to land. Factors related to the accident were: darkness, the adverse weather conditions, and failure of company/operator/management personnel to provide current weather.
Final Report:

Crash of a Boeing 737-204 in Tucson

Date & Time: Dec 30, 1989 at 1910 LT
Type of aircraft:
Operator:
Registration:
N198AW
Survivors:
Yes
Schedule:
Phoenix - Tucson
MSN:
19710
YOM:
1968
Location:
Crew on board:
5
Crew fatalities:
Pax on board:
125
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10600
Captain / Total hours on type:
3970.00
Aircraft flight hours:
62466
Aircraft flight cycles:
38827
Circumstances:
During approach, a fire erupted in the wheel well of the 22-year old airplane. The fire burned thru the hydraulic lines rendering the a, b, and standby hydraulic systems inoperative. The crew landed the airplane using the emergency manual reversion flight control system. However, the airplane was unable to stop on the runway because of the previous failures of the check valves in the backup hydraulic accumulator pressure systems for the #2 thrust reverser and the inboard pair of wheel brakes. During the 2 minutes rollout, the airplane traversed 14,000 feet, overran the runway end, and collided with a concrete structure which collapsed the nose gear. The airplane had recently undergone a 'C' check during which the operator's mechanics failed to observe and repair an electric wire which had been chafing against a hydraulic line. On the accident flight the energized wire arced, punctured the line, and ignited the escaping hydraulic fluid. The hydraulic check valves had failed earlier due to mechanical wear.
Probable cause:
Failure of the operator's maintenance personnel to detect an electrical wire which had chafed against a hydraulic line and which eventually arced causing a leak in the hydraulic line and subsequent fire and hydraulic system failure. In addition, previous wear of check valves in the backup hydraulic systems prevented the airplane from stopping on the runway. A contributing factor was the airplane manufacturer's inadequate guidance for maintaining the hydraulic components.
Final Report:

Crash of a McDonnell Douglas MD-82 in Detroit: 156 killed

Date & Time: Aug 16, 1987 at 2045 LT
Type of aircraft:
Operator:
Registration:
N312RC
Flight Phase:
Survivors:
Yes
Schedule:
Saginaw - Detroit - Phoenix - Santa Ana
MSN:
48090
YOM:
1981
Flight number:
NW255
Crew on board:
6
Crew fatalities:
Pax on board:
149
Pax fatalities:
Other fatalities:
Total fatalities:
156
Captain / Total flying hours:
20859
Captain / Total hours on type:
1359.00
Copilot / Total flying hours:
8044
Copilot / Total hours on type:
1604
Aircraft flight hours:
14928
Circumstances:
A McDonnell Douglas DC-9-82 operating Northwest Airlines flight 255 was destroyed when it crashed onto a road during takeoff from Detroit-Metropolitan Wayne County Airport, Michigan, USA. Just one of the 155 occupants survived the accident. Additionally, Two persons on the ground were killed. Flight NW255 was a regularly scheduled passenger flight between Saginaw, Michigan and Santa Ana, California, with en route stops at Detroit and Phoenix, Arizona. About 18:53, flight 255 departed Saginaw and about 19:42 arrived at its gate at Detroit. About 20:32, flight 255 departed the gate with 149 passengers and 6 crewmembers on board. During the pushback, the flightcrew accomplished the BEFORE (engine) START portion of the airplane checklist, and, at 20:33, they began starting the engines. The flight was then cleared to "taxi via the ramp, hold short of (taxiway) delta and expect runway three center [3C] (for takeoff)..." The ground controller amended the clearance, stating that the flight had to exit the ramp at taxiway Charlie. The crew was requested to change radio frequencies. The first officer repeated the taxi clearance, but he did not repeat the new radio frequency nor did he tune the radio to the new frequency. At 20:37, the captain asked the first officer if they could use runway 3C for takeoff as they had initially expected 21L or 21R. After consulting the Runway Takeoff Weight Chart Manual, the first officer told the captain runway 3C could be used for takeoff. During the taxi out, the captain missed the turnoff at taxiway C. When the first officer contacted ground control, the ground controller redirected them to taxi to runway 3C and again requested that they change radio frequencies. The first officer repeated the new frequency, changed over, and contacted the east ground controller. The east ground controller gave the flight a new taxi route to runway 3C, told them that windshear alerts were in effect, and that the altimeter setting was 29.85 inHg. The flightcrew acknowledged receipt of the information. At 20:42, the local controller cleared flight 255 to taxi into position on runway 3C and to hold. He told the flight there would be a 3-minute delay in order to get the required "in-trail separation behind traffic just departing." At 20:44:04, flight 255 was cleared for takeoff. Engine power began increasing at 20:44:21. The flightcrew could not engage the autothrottle system at first, but, at 20:44:38, they did engage the system, and the first officer called 100 knots at 20:44:45. At 20:44:57, the first officer called "Rotate." Eight seconds later, the stall warning stick shaker activated, accompanied by voice warnings of the supplemental stall recognition system (SSRS). The takeoff warning system indicating that the airplane was not configured properly for takeoff, did not sound at any time prior or during takeoff. After flight 255 became airborne it began rolling to the left and right before the left wing hit a light pole in a rental car lot. After impacting the light pole, flight 255 continued to roll to the left, continued across the car lot, struck a light pole in a second rental car lot, and struck the side wall of the roof of the auto rental facility in the second rental car lot. The airplane continued rolling to the left when it impacted the ground on a road outside the airport boundary. The airplane continued to slide along the road, struck a railroad embankment, and disintegrated as it slid along the ground. Fires erupted in airplane components scattered along the wreckage path. Three occupied vehicles on the road and numerous vacant vehicles in the auto rental parking lot along the airplane's path were destroyed by impact forces and or fire. One passenger, a 4-year-old child was injured seriously.
Probable cause:
The flight crew's failure to use the taxi checklist to ensure that the flaps and slats were extended for take-off. Contributing the accident was the absence of electrical power to the airplane take-off warning system which thus did not warn the flight crew that the airplane was not configured properly for take-off. The reason for the absence of electrical power could not be determined.
Final Report:

Crash of a Cessna 441 Conquest in Flagstaff: 2 killed

Date & Time: Feb 20, 1987 at 1845 LT
Type of aircraft:
Operator:
Registration:
N6858S
Flight Type:
Survivors:
No
Schedule:
Phoenix - Flagstaff
MSN:
441-0253
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2311
Captain / Total hours on type:
24.00
Aircraft flight hours:
3349
Circumstances:
The aircraft was on an emergency medical service (ems/medevac) flight with a pilot and a flight nurse aboard to transport a maternity patient from Flagstaff to Phoenix. During a night arrival, the pilot began a VOR-A approach in IMC, then he reported a problem with his avionics and elected to make a missed approach. During the missed approach, he said that he 'lost' an inverter, then reported the gyros were inoperative. Radar vectors were being provided when he stated 'we have big trouble here.' Soon thereafter, radar and radio contacts were lost and the aircraft crashed approximately 7 miles southeast of the airport. During impact, the aircraft made a deep crater and was demolished. No preimpact engine or airframe failure was found. An investigation revealed the #2 (copilot's) attitude indicator was inoperative on the previous flight. A discrepancy report was taken to the avionics department, but the requested entry was not made in the aircraft form-4. The pilot took off before corrective action was taken. The operations manual requested 1,000 hours multi-engine time as pic and training by esignated cfi's. The pilot had approximately 837 hours multi-engine time, recorded 9 training flights in N6858S with non-designated instructors, completed a part 135 flight check on 2/17/88. Both occupants were killed.
Probable cause:
Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: approach
Findings
1. Maintenance, recordkeeping - improper
2. Procedures/directives - not followed
3. (f) inadequate surveillance of operation - company/operator mgmt
4. (c) electrical system - undetermined
5. Electrical system, inverter - inoperative
6. Flight/nav instruments, attitude indicator - inoperative
----------
Occurrence #2: loss of control - in flight
Phase of operation: approach
Findings
7. (f) light condition - dark night
8. (f) weather condition - low ceiling
9. (f) weather condition - snow
10. (c) aircraft handling - not maintained - pilot in command
11. (c) spatial disorientation - pilot in command
12. (f) lack of total experience in type of aircraft - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report: